Posts Tagged ‘diagnosis’

NCDEU 2012

June 13th, 2012

I just attended the annual NCDEU meeting—this year in Phoenix, AZ. NCDEU stands for New Clinical Drug Evaluation Unit (formerly ECDEU, Early Clinical Drug Evaluation Unit) These are now meaningless acronyms, but it was originally a symposium of clinical psychopharmacology researchers funded by NIMH. NIMH has recently relinquished “ownership” of the meeting to the American Society of Clinical Psychopharmacology, but it, along with its sister institutes NIDA and NIAAA as well as the FDA, retains a partnership stake and roll [?a role] in the program.

No one was certain how this meeting, which many of us are devoted to, would survive the transition from NIMH’s leadership. But this year’s program, with ASCP in the lead, was a sparkling success: in attendance, participation, enthusiasm and—most of all—groundbreaking science.

Meetings evolve. ECDEU/NCDEU began as a methods-focused conclave in the early days of biological psychiatry. Over the decades, it evolved to incorporate understanding of brain function, psychosocial interventions, and combined treatments. NCDEU became a unique assembly of industry, government, and university scientists, regulators, teachers, and clinicians. The papers, posters, and panels contained cutting-edge information, but much of the spark came in the informal conversations, from which flowed new research ideas and collaborations.

This year’s agenda included news on innovative treatments and new data on old techniques and agents. A bold new diagnostic methodology, the NIMH Research Domain Criteria (RDoC) is shifting the focus from DSM categories to dimensions and traits, in the hope of mapping disorders to biological underpinnings and the human genome. Whether—and when—this will bear fruit in furthering understanding of brain disorders and creating new and personalized treatments remains to be seen. It could take years or even decades to unfold.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

Overall, the information imparted at NCDEU 2012 was invigorating, and the energy in the meeting has never been higher. With the disclosure that I sit on ASCP’s board and have an abiding passion for its mission and NCDEU’s future, I encourage my faculty members and BTP readers to think about ASCP membership and attending NCDEU. BTP (and the Journal of Clinical Psychiatry) are partners with ASCP, which is a dynamic and growing organization. Coming away from this year’s meeting, I am very optimistic about psychiatry’s future.

BAL

January 3rd, 2011

When I was in medical school and during my medical internship, it was axiomatic that we treated patients—not laboratory values. That axiom remains valid in today’s high-tech medicine.

I find that sometimes my non-psychiatric colleagues fail to appreciate the gravity of alcohol and sedative-hypnotic withdrawal, a syndrome that carries a high mortality risk. And sometimes a patient can come into an ER with alcohol on his breath and a high blood alcohol level (BAL) and still be in impending delirium tremens (DTs).

A woman walked into our ER. (Yes, she really walked.) She spoke coherently but was agitated. Her BAL was the highest I’ve ever seen: 455! Within an hour she had a seizure and was in florid DTs. She had no other neurological abnormalities on physical exam or scan. So with a BAL that high, she was actually in alcohol withdrawal. She must have been routinely consuming a huge quantity of alcohol, with a high level of dependence.

We treat patients—not lab values.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

Cognition and Depression

December 27th, 2010

Someday psychiatric diagnoses will entail biological tests. Today we rely on clinical knowledge.

Cognitive function can suffer when someone is depressed. Depressed patients often have trouble concentrating. Their minds wander. They are less productive, more distractible. But some elements of memory or cognitive dysfunction suggest other diagnoses.

Some years back I took a phone call from a university administrator in his late 60s. He had driven up to the keypad in his gated home and had forgotten the numeric combination. He assumed it was the stress he was under and that he should talk to me, a psychiatrist. Anxiety, depression, stress—none of these sounded right to me as an explanation of forgetting an over-learned four-digit code he used daily. I asked him to see his primary-care doctor immediately, and to be safe, I talked to his physician with the same sense of urgency. It turned out his blood pressure was extremely high (that’s where the stress factored in). He had experienced an encephalopathy. When his blood pressure returned to normal, his
cognition and memory also normalized.

The other day I got a call from an internist at my medical college. An 80-year-old patient who was also a long-time friend was upset about his son’s choice of a partner. The man’s wife believed he was depressed and phoned my colleague requesting that he prescribe an antidepressant for her husband. He preferred that his patient talk to a psychiatrist first. I phoned the man and was troubled when he described symptoms he attributed to family tensions. Having been married for over 40 years, he had recently called his wife by a wrong name several times. And when she drove to pick him up a day earlier, at first he didn’t recognize her. As in the case above, these sounded more “organic” to me. Differential
diagnoses that came to my mind included primary and secondary brain tumors (possibly setting off seizures), hypertension, other encephalopathies. Sometimes Alzheimer’s or other dementias begin in a stuttering fashion. In any case, the mental lapses he was experiencing didn’t sound to me like depression.

But when I met him in person, the picture changed. Showing a full and appropriate range of affect in the interview, and able to describe pleasurable activities with passion and relish, he was not depressed. Moreover, his short- and long-term memory and executive functions were impressive. Perhaps he would develop dementia over the coming years, as many people over 80 years do—but he wasn’t demonstrating it today. Instead, he described mounting marital tensions. At the end of my consultation, we discussed how he and his wife might address these. (His internist saw him and ordered additional tests. All were negative.)

Someday psychiatric diagnoses will entail biological tests. Today we rely on clinical knowledge.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry